ALACHUA COUNTY COMMUNITY HEALTH ASSESSMENT

ALACHUA COUNTY COMMUNITY HEALTH ASSESSMENT JUNE 2016

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ALACHUA COUNTY COMMUNITY HEALTH ASSESSMENT (CHA) Contents Executive Summary 4 The Alachua Community Health Assessment (CHA) Process 4 Organization of the Community Health Assessment (CHA) Report 5 Using the Community Health Assessment 6 Technical Appendix 6 Community Health Status Assessment 8 Introduction 8 Population 9 County Health Rankings 11 Health factors 14 Socioeconomics 14 Health Behaviors 18 Healthcare Access 21 Health Outcomes 25 Life Expectancy 25 Mortality 27 Maternal and Infant Health 28 Violence 29 Key Insights from the data 29 Poverty 29 Mental Health 29 Alcohol Abuse 29 Asthma 30 Low Birthweight and Infant Mortality 30 Cancer 30 Dental 30 Cervical Cancer Screenings 30 Food Insecurity 30

ALACHUA COUNTY COMMUNITY HEALTH ASSESSMENT (CHA) Sexually Transmitted Infections (STIs) 30 Obesity 30 Community Themes and Strengths Assessment 31 Community Health Surveys 31 Methodology 31 Observations 33 Forces of Change Assessment 42 Methods 42 Local Public Health System Assessment 62 Methodology 62 Observations 64 Identification of Strategic Priorities and Recommendations for Next Steps 65 Intersecting Themes and Key Considerations 65 Intersecting themes/health needs and issues 65 Key Considerations 66 Interventions: General Approaches and Specific Opportunities 66 Acknowledgments 83 Appendix A - Community Health Survey Instruments Appendix B - Forces of Change Assessment Instrument

ALACHUA COUNTY COMMUNITY HEALTH ASSESSMENT (CHA) Executive Summary THE ALACHUA COMMUNITY HEALTH ASSESSMENT (CHA) PROCESS In 2011 and 2012 the Florida Department of Health in Alachua County led the process to produce an Alachua County Community Health Needs Assessment. The Needs Assessment included the involvement of a number of diverse organizations and individuals representing public and private organizations, community groups, healthcare providers, patients and others. As a result of that collaboration there emerged a collective vision for Alachua County to be A community where everyone can be healthy. That assessment process also resulted in the identification of two overarching broad strategic goals: 1) Residents of Alachua County will be able to access comprehensive primary care and preventive services and 2) Promote wellness among all Alachua County residents. As part of the initial assessment and planning process, a community health implementation plan (CHIP) was developed, and a steering committee formed. Several volunteer work groups were developed to address specific initiatives related to the two overarching goals. The work groups included: Healthy Communities (wellness); Diabetes education work group, the Safety Net Coalition (access); Mental Health Coalition and the Oral Health Coalition. The CHIP steering committee has continued to meet quarterly since the previous CHNA was approved and has monitored and measured the initial progress of work group activities and specific initiatives identified in the corresponding CHIP plan. On August 11, 2015, a meeting was held at the Florida Department of Health in Alachua County to discuss updating the 2012 Alachua County Community Health Improvement Plan (CHIP). At the meeting, community partners discussed the option to either update the existing CHIP or to move forward by partnering with UF Health Shands Hospital in order to develop a new health improvement plan for the county. The CHIP committee voted to move forward with the new assessment and partnership, and as a result the Alachua County Community Health Assessment (CHA) was launched. The Alachua County CHA process began in December 2015 when the Florida Department of Health in Alachua County and UF Health Shands Hospital came together to form the Alachua County Community Health Assessment Steering Committee. The Florida Department of Health in Alachua County and UF Health Shands Hospital organized and identified key community leaders to be a part of the Alachua Steering Committee team, representing different geographical and professional areas of Alachua County. For information about the members of the Alachua County Community Health Assessment Steering Committee, please see the Acknowledgements page. The Alachua Steering Committee engaged the services of WellFlorida Council to complete the assessment. WellFlorida Council is the statutorily designated (F.S. 408.033) local health council that serves Alachua County along with 15 other north central Florida counties. The mission of WellFlorida Council is to forge partnerships in planning, research and service that build healthier communities. WellFlorida achieves this mission by providing communities the insights, tools and services necessary to identify their most pressing COMMUNITY HEALTH STATUS ASSESSMENT PAGE 4

ALACHUA COUNTY COMMUNITY HEALTH ASSESSMENT (CHA) issues (e.g. community health assessments and community health improvement plans) and to design and implement approaches to overcoming those issues. The Alachua Steering Committee team and WellFlorida based the 2016 Community Health Assessment (CHA) effort on a nationally recognized model and best practice for completing needs assessments and improvement plans called Mobilizing for Action through Planning and Partnerships (MAPP). The MAPP tool was developed by the National Association of County and City Health Officials (NACCHO) in cooperation with the Public Health Practice Program Office, Centers for Disease Control and Prevention (CDC). NACCHO and the CDC s vision for implementing MAPP is "Communities achieving improved health and quality of life by mobilizing partnerships and taking strategic action." At the heart of the MAPP process are the following core MAPP assessments: Community Health Status Assessment (CHSA) Community Themes and Strengths Assessment (CTSA) Forces of Change Assessment (FCA) Local Public Health Systems Assessment (LPHSA) These four MAPP assessments work in concert to identify common themes and considerations in order to hone in on the key community health needs. These four MAPP assessments are fully integrated into the 2016 Alachua County CHA. Note that this document is a health needs assessment and that its purpose is to uncover or substantiate the health needs and health issues in Alachua County. ORGANIZATION OF THE COMMUNITY HEALTH ASSESSMENT (CHA) REPORT The 2016 Alachua County CHA is comprised of the following main sections: Executive Summary. This section includes an overview of the CHA process, description of the organization of the CHA report, and insights on using the CHA. Community Health Status Assessment. This section is one of the core MAPP assessments. Detailed in this section are various mortality and morbidity indicators, health factors and health behaviors that describe the overall health status of Alachua County and compare that status (for most data) to Florida. Essentially, this is a technical overview of highlights found in the existing data for Alachua County and the state, and discusses highlights in the data based on the information compiled in the Alachua County Technical Appendix. Community Themes and Strengths Assessment. While the previous section The Community Health Status Assessment is largely based on in-depth quantitative analysis of existing community and health system administrative data sets, this section provides a qualitative perspective on health issues and the health system from the community at-large, and fulfills the MAPP requirement by providing community members the opportunity to provide feedback on the health of Alachua County and its residents. The following surveys were developed and administered: a Community Member Survey, a Business Leader Survey, and a Provider Survey. COMMUNITY HEALTH STATUS ASSESSMENT PAGE 5

ALACHUA COUNTY COMMUNITY HEALTH ASSESSMENT (CHA) Forces of Change Assessment. Alachua Steering Committee members identified and assembled a diverse gathering of community leaders to participate in a strategic Forces of Change meeting to identify Events, Trends, and Factors in the Alachua County Community that have an impact on public health in Alachua County. Local Public Health Systems Assessment. The Alachua County CHA Steering Committee as well as several identified members of the community were assembled to participate in the Local Public Health Systems Assessment. This poll-style group activity called on participants to identify on the components, activities, competencies and capacities of Alachua County s local public health system, as well as asked participants to rate how well the Essential Services (identified by The National Public Health Performance Standards program and partners) are being provided to the Alachua County community. Identification of Strategic Priorities and Recommendations for Next Steps. This section begins with a brief summary of the intersecting themes that cut across all sections of the CHA and some of the key considerations generated from those common themes. Following the summary of these themes and considerations, this section details some general suggestions, or promising practices, about how to move forward with the identified needs; provides some specific examples of approaches to address these needs; and discusses some community organization principles that will need to be addressed to ensure that true community health improvement is realized. USING THE COMMUNITY HEALTH ASSESSMENT The 2016 Alachua County Health Assessment is designed to address the core MAPP assessments that are designated as key components of a best practice needs assessment designed by NACCHO and the CDC. The identification of the global health needs and health issues of the community comes from an analysis of the intersecting themes in each of these sections. Overall, the main objectives of this CHA are the following: To accurately depict Alachua County s key health issues based on common themes from the core MAPP assessments; To identify potential strategic issues and some potential approaches to addressing those issues; To provide insight and input to the next phase of the MAPP assessment/improvement process (i.e. development of the Community Health Improvement Plan [CHIP]); To provide the community with a rich data resource not only for the next phase of CHIP creation but also for ongoing resource for program development and implementation as well as evaluation of community health improvement. TECHNICAL APPENDIX While the 2016 Alachua County Community Health Assessment is undoubtedly a stand-alone document, the CHA has been designed to work in concert with an accompanying Technical Appendix. While the CHA presents data and issues at a higher more global level for the community, all of the data in the CHA that has identified these global health issues for the community are addressed in granular level detail in the Technical Appendix. Thus, for most data that are briefly addressed in the main CHA, the Technical Appendix COMMUNITY HEALTH STATUS ASSESSMENT PAGE 6

ALACHUA COUNTY COMMUNITY HEALTH ASSESSMENT (CHA) presents these data in a very fine level of detail breaking data sets down where appropriate and when available. The Technical Appendix is an invaluable companion resource to the CHA, as it will allow the community to dig deeper into the issues in order to more readily understand the community health needs of Alachua County. The Technical Appendix is comprised of more than 80 tables supporting material across over 230 pages. The Technical Appendix is organized into the following major data sections: Demographics and Socioeconomics Mortality Birth Data Health Behaviors Infectious Disease Healthcare Access and Utilization Community Health Survey Full Responses Residents Community Health Survey Full Responses Business Leaders Community Health Survey Full Responses Physicians The National Public Health Performance Standards: Local Public Health System Report Note that many of the data tables in this CHA report and in the Technical Appendix report contain standardized rates for the purpose of comparing Alachua County to the state of Florida as a whole. It is advisable to interpret these rates with caution when incidence rates are low (the number of new cases are small); thus small variations from year to year can result in substantial shifts in the standardized rates. COMMUNITY HEALTH STATUS ASSESSMENT PAGE 7

ALACHUA COUNTY COMMUNITY HEALTH ASSESSMENT (CHA) Community Health Status Assessment INTRODUCTION This portion of the Community Health Assessment provides a narrative summary of the data presented in the Technical Appendix which includes analysis of social determinants of health, community health status, and health system assessment. Social determinants of health include socioeconomic demographics, poverty rates, population demographics, uninsured population estimates and educational attainment levels and the like. Data for the Technical Appendix were compiled and tabulated from multiple sources including the United States Census Bureau, the Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System (BRFSS), the American Community Survey (ACS), the Florida Department of Health's Office of Vital Statistics, and Florida's Agency for Health Care Administration (AHCA). When data are available, a comparison is provided with the state of Florida. The Technical Appendix also includes data from the UF Health Shands Hospital Needs Assessment Platform, an initiative supported by the UF Health Shands Hospital. The UF Health Shands Hospital Needs Assessment Platform draws from national indicators for health and is maintained by the Healthy Communities Institute. Target values on the UF Health Shands Hospital Needs Assessment Platform include the nation-wide Healthy People 2020 (HP2020) goals as well as locally set goals. Healthy People 2020 goals are national objectives for improving the health of the nation set by the Department of Health and Human Services (DHHS) Healthy People Initiative. For all value comparisons, the scoring depends on whether the county value is better or worse than the comparison value, as well as how close the county value is to the target value. Data from this report can be used to explore and understand the health needs of Alachua County and its various communities and sub-populations in order to plan interventions and apply for continuing and new program funding. The written organization of this needs assessment is in alignment with the growing national focus on County Health Rankings by the Robert Wood Johnson Foundation and the University of Wisconsin. The County Health Rankings provide a snapshot of a community s health, which identifies a starting point for discussing and investigating the health of the community. The Technical Appendix serves to supplement data used to determine the County Health Rankings; a narrative summary of the Technical Appendix is presented in this document. The following summary of the Technical Appendix data is broken down into several components: Population County Health Rankings Health Factors Socioeconomics Health Behaviors Healthcare Access COMMUNITY HEALTH STATUS ASSESSMENT PAGE 8

ALACHUA COUNTY COMMUNITY HEALTH ASSESSMENT (CHA) Health Outcomes Life Expectancy Mortality Maternal and Infant Health Violence Key Insights The data presented in this summary include references to specific tables in the Technical Appendix so that users can see the numbers and the rates in context. POPULATION The demographic characteristics of Alachua County residents are reviewed in this section. Data in this section is presented for Alachua County and compared to Florida. Data indicators include population breakdown by age, race and gender. The map below displays the zip code areas for Alachua County, Florida. FIGURE 1: ZIP CODES FOR ALACHUA COUNTY, FLORIDA Source: Figure 1, Alachua County Technical Appendix 2016, prepared by WellFlorida Council. COMMUNITY HEALTH STATUS ASSESSMENT PAGE 9

ALACHUA COUNTY COMMUNITY HEALTH ASSESSMENT (CHA) Alachua County has a population of 247,336 according to the 2010 U.S. Census Bureau (Table 5, Technical Appendix). Alachua County is located in North Central Florida. The county shares borders with Columbia, Union and Bradford Counties to the north, Levy and Marion Counties to the south, Putnam County to the East and Gilchrist County to the west. Gainesville is the largest incorporated municipality in the county according to the U.S. Census Bureau (Table 5, Technical Appendix). Additionally, 78.8 percent of Alachua County s population is considered urban and 21.2 percent is considered rural. This is in contrast to Florida s population, which is 91.2 percent urban and 8.8 percent rural (Table 17, Technical Appendix). The following figure provides a visual representation of Alachua County population by race. As seen in Figure 2 below, the majority of Alachua County residents are White (69.6%). In Alachua County, 48.4% of the population are males and 51.6% are females (Table 7, Technical Appendix). FIGURE 2: POPULATION BY RACE IN ALACHUA COUNTY White 69.6% Two or More Races 2.64% Some Other Race 1.7% Black 20.3% American Indian/Alaska Native 0.3% Asian 5.35% Source: Table 5, Alachua County Technical Appendix 2016, prepared by WellFlorida Council. COMMUNITY HEALTH STATUS ASSESSMENT PAGE 10

ALACHUA COUNTY COMMUNITY HEALTH ASSESSMENT (CHA) The following table provides information regarding the population by selected age groups in Alachua County as compared to the state of Florida as a whole. TABLE 1: POPULATION BY AGE GROUPS Age Group Percent of Alachua County Population Percent of Florida Population 0-4 5.3 5.7 5-9 4.7 5.7 10-14 4.7 6.0 15-24 26.3 13.1 25-34 15.0 12.2 35-44 10.3 12.9 45-54 11.9 14.6 55-64 11.0 12.4 65-74 5.9 9.2 75-84 3.4 5.8 85+ 1.5 2.3 Source: Table 8, Alachua County Technical Appendix 2016, prepared by WellFlorida Council. As seen in the table above, population by age group in Alachua County varies slightly from the trends for the state of Florida, with the greatest difference existing in the 15-24 age group (26.3 percent in Alachua County; 13.1 percent in Florida). COUNTY HEALTH RANKINGS The County Health Rankings are a key component of the Mobilizing Action Toward Community Health (MATCH) collaboration project between the Robert Wood Johnson Foundation (RWJ) and the University of Wisconsin Population Health Institute. Counties receive a rank relative to the health of other counties in the state. Counties having high ranks, e.g. 1 or 2, are considered to be the healthiest. Health is viewed as a multi-factorial construct. Counties are ranked relative to the health of other counties in the same state on the following summary measures: I. Health Outcomes--rankings are based on an equal weighting of one length of life (mortality) measure and four quality of life (morbidity) measures. II. Health Factors--rankings are based on weighted scores of four types of factors: a. Health behaviors (7 measures) b. Clinical care (5 measures) c. Social and economic (7 measures) d. Physical environment (5 measures) COMMUNITY HEALTH STATUS ASSESSMENT PAGE 11

ALACHUA COUNTY COMMUNITY HEALTH ASSESSMENT (CHA) The most recent Rankings available are for 2016. In 2016, Alachua County ranked 10 th for health factors and 25 th for health outcomes, out of Florida s 67 counties. The following explanation is given by RWJ regarding the calculation of County Health Rankings: The County Health Rankings, is a collaboration between the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute, measure the health of nearly all counties in the nation and rank them within states. The Rankings are compiled using county-level measures from a variety of national and state data sources. These measures are standardized and combined using scientifically-informed weights. The County Health Rankings are based on counties and county equivalents (ranked places). Any entity that has its own Federal Information Processing Standard (FIPS) county code is included in the Rankings. We only rank counties and county equivalents within a state. The major goal of the Rankings is to raise awareness about the many factors that influence health and that health varies from place to place, not to produce a list of the healthiest 10 or 20 counties in the nation and only focus on that. The County Health Rankings team synthesizes health information from a variety of national data sources to create the Rankings. Most of the data we use are public data available at no charge. Measures based on vital statistics, sexually transmitted infections, and Behavioral Risk Factor Surveillance System (BRFSS) survey data were calculated for us by staff at the National Center for Health Statistics and other units of the Centers for Disease Control and Prevention (CDC). Measures of health care quality were calculated for us by staff at The Dartmouth Institute. The County Health Rankings team draws upon the most reliable and valid measures available to compile the Rankings. Where possible, we provide the margin of errors (95% confidence intervals) for our measure values. In many cases, the values of specific measures in different counties are not statistically different from one another; however, when combined using our model, those various measures produce the different rankings. The County Health Rankings are compiled from many different types of data. To calculate the ranks, we first standardize each of the measures. The ranks are then calculated based on weighted sums of the standardized measures within each state. The county with the lowest score (best health) gets a rank of #1 for that state and the county with the highest score (worst health) is assigned a rank corresponding to the number of places we rank in that state. For more detailed information on how County Health Rankings are measured, please visit http://www.countyhealthrankings.org/ranking-methods. COMMUNITY HEALTH STATUS ASSESSMENT PAGE 12

ALACHUA COUNTY COMMUNITY HEALTH ASSESSMENT (CHA) TABLE 2: MEASURES FOR HEALTH OUTCOMES AND HEALTH FACTORS FOR ALACHUA COUNTY, 2010-2016 (RANKS BASED ON 67 FL COUNTIES) 2010 2011 2012 2013 2014 2015 2016 HEALTH OUTCOMES 18 16 15 18 17 18 25 Mortality/Length of Life 16 7 10 16 16 12 13 Morbidity/Quality of Life 24 25 24 21 19 19 40 HEALTH FACTORS 8 6 5 4 2 2 10 Health Behavior 18 17 13 11 8 9 33 Clinical Care 1 1 1 1 1 1 1 Social & Economic Factors 11 9 16 12 13 14 13 Physical Environment 49 23 31 28 21 18 12 Source: Table 1, Alachua County Technical Appendix 2016, prepared by WellFlorida Council. Please note: Do not compare 2016 ranks for quality of life and health behaviors with previous ranks. In previous RWJ releases, the CDC provided BRFSS data with estimates based on seven years of combined data. In the year 2016, only 2014 data was used to construct estimates. Historically, BRFSS was based on landline telephones. In 2011, cell-only users were included for the first time. According to RWJ, the data from 2011 onward could not be easily combined with earlier years to create the RWJ county estimates. The CDC only provided 2014 county-by-county data to RWJ in 2016, using a different modeling technique in order to include cell phone data. The overall County Health Rankings for Alachua County for 2016 are generally positive. However, there are certain rankings that stand out when examining the Alachua rankings. Morbidity and Quality of Life in 2016 is ranked 40 out of 67 counties, and Health Behavior for Alachua is ranked 33, around mid-range for Florida. In 2016, Clinical Care in Alachua County fares much better than the other Florida counties as it is ranked number 1 in the state. In regards to individual Health Outcomes or individual Health Factors for 2016, it is notable that Alachua County fares slightly worse than the state on adult smoking, excessive drinking and sexually transmitted infection rate as seen in Table 3 below. Alachua County fares better than the state of Florida for physical inactivity, teen birth rate, and uninsured adults as seen in Table 3. COMMUNITY HEALTH STATUS ASSESSMENT PAGE 13

ALACHUA COUNTY COMMUNITY HEALTH ASSESSMENT (CHA) TABLE 3: ALACHUA COUNTY HEALTH RANKINGS, 2016 Measure Alachua County Florida Adult smoking (Percent) 18.2 16.2 Adult obesity (Percent) 25.3 25.5 Physical inactivity (Percent) 19.2 23.9 Access to exercise opportunities (Percent) 83.5 92.0 Excessive drinking (Percent) 20.3 18.3 Alcohol-impaired driving deaths (Percent) 28.3 29.1 Sexually transmitted infections rate ((Chlamydia only) 721.5 415.1 Teen birth rate 19.5 33.5 Uninsured adults (Percent) 19.1 24.3 Diabetic screening (Percent) 85.3 85.5 Mammography screening (Percent) 68.0 65.0 Diabetic screening (Percent) 85.3 85.5 Source: Table 2, Alachua County Technical Appendix 2016, prepared by WellFlorida Council. The concept of Health Factors and Health Outcomes are a useful method for analyzing and understanding the current state and needs of the community. To further explore Health Factors and Health Outcomes affecting Alachua County residents, additional data was gathered and tabulated in the Technical Appendix. The following sections explore and provide analysis of data within the Technical Appendix. HEALTH FACTORS Health factors influence the health of a community and include socioeconomic factors, health behaviors and clinical care. The Technical Appendix includes data on current statistics on education, employment, income and poverty status. It is important to note that these indicators can significantly affect populations through a variety of mechanisms including material deprivation, psychosocial stress, barriers to healthcare access and heightened risk of acute and/or chronic illness. SOCIOECONOMICS Socioeconomic indicators lend to factors that, if an intervention was made to drastically change these data points in Alachua County, the result would have the largest impact on the heath of citizens. Not surprisingly, socioeconomic factors are the most difficult to change and move the needle in the positive direction, as they are mainly the result of larger-scale societal factors that take very long periods of time to cycle. Because of COMMUNITY HEALTH STATUS ASSESSMENT PAGE 14

ALACHUA COUNTY COMMUNITY HEALTH ASSESSMENT (CHA) this, it is important to keep these factors in mind when developing plans for a community s health in order to address these disparities whenever possible. Poverty For the years 2010-2014, the percent of Alachua County s population for all ages who live in poverty has been higher than the state of Florida. 21.6 percent of Alachua County s population for all ages was estimated to live at or below the poverty threshold in 2014, compared to the Florida percent of 16.6 for 2014 (Table 34, Technical Appendix). The percent of Alachua County s children (under the age of 18) in poverty remains similar to Florida in recent years, 2012-2013, though it has decreased in recent years, as seen in Figure 3. In 2014, 22.1 percent of Alachua County residents under the age of 18 are in poverty, compared to Florida at 24.2 percent (Table 34, Technical Appendix). For trend data on poverty in Alachua County, see Figure 3. In Alachua County, 21.4 percent of white residents live in poverty, which is around 35,272 individuals. 36.3 percent of black residents in Alachua County live in poverty, which is around 17,749 individuals (from 2010-2014, Table 39, Technical Appendix). In the state of Florida. 14.0 of white Floridians live in poverty and 28.1 percent of black Floridians live in poverty (from 2010-2014, Table 39, Technical Appendix). Additionally, 22.9 percent of households in Alachua County are in poverty (15.2 percent in Florida) from 2010-2014 (Table 40, Technical Appendix). COMMUNITY HEALTH STATUS ASSESSMENT PAGE 15

ALACHUA COUNTY COMMUNITY HEALTH ASSESSMENT (CHA) FIGURE 3: PERCENT OF PERSONS IN POVERTY BY SELECTED AGES, ALACHUA COUNTY AND FLORIDA, 2010-2014 29 27 25 23 21 19 17 15 2010 2011 2012 2013 2014 Source: Table 34, Alachua County Technical Appendix 2016, prepared by WellFlorida Council. Food Access Alachua All Ages Florida All Ages Alachua Children Florida Children Food insecurity is defined by the U.S. Department of Agriculture (USDA) as limited or uncertain availability of nutritionally adequate foods or uncertain ability to acquire these foods in socially acceptable ways. In Alachua County, the rate of Food Insecurity is 19.8 percent in 2013, which is higher than the state of Florida (17.0 percent) and the United States (15.8 percent). Additionally, the Child Food Insecurity Rate for Alachua County in 2013 is 23.3 percent, compared to Florida at 26.7 percent and the US at 21.4 percent (Table 71, Technical Appendix). COMMUNITY HEALTH STATUS ASSESSMENT PAGE 16

ALACHUA COUNTY COMMUNITY HEALTH ASSESSMENT (CHA) FIGURE 4: FOOD INSECURITY RATE (PERCENT), ALACHUA COUNTY, FLORIDA AND UNITED STATES, 2011-2013. 2013 2012 2011 0 5 10 15 20 25 United States Florida Alachua County Source: Table 71, Alachua County Technical Appendix 2016, prepared by WellFlorida Council. In Alachua County, the percent of households with Supplemental Security Income (SSI) is slightly less than the Florida percent from 2010-2014 (4.0 in Alachua compared to 4.9 FL). 11.6 percent of households in Alachua County are on Food Stamps compared to 14.3 percent of households for Florida (Table 29, Technical Appendix). Income For years 2010 2014, the estimated median household income (all races) in Alachua County was $42,045 compared to $47,212 in Florida as a whole. Median household income for White Alachua County residents was $49,195 compared to the median household income for Black Alachua County residents of $25,687 (Table 42, Technical Appendix). See Figure 5 for details regarding the per capita incomes in Alachua County compared to Florida as a whole. COMMUNITY HEALTH STATUS ASSESSMENT PAGE 17

ALACHUA COUNTY COMMUNITY HEALTH ASSESSMENT (CHA) FIGURE 5: PER CAPITA INCOME, 2010-2014 ESTIMATES 35,000 30,000 25,000 20,000 15,000 10,000 5,000 - All Races White Black Hispanic Alachua County Florida Source: Table 42, Alachua County Technical Appendix 2016, prepared by WellFlorida Council. Employment Unemployment rates in Alachua County tend to track lower than Florida unemployment rates. In 2014, the unemployment rate in Alachua County was 4.9 compared to 6.1 in Florida; in 2015, unemployment in Alachua County was at 4.5 percent compared to Florida at 5.4 percent (Table 49, Technical Appendix). Educational Attainment Estimates for the years 2010 2013 suggest 8.2 percent of the adult population in Alachua County has less than a high school diploma, 40.7 percent has completed high school, and 51.1 percent has completed a college degree. In Florida, 13.5 percent of the adult population has less than a high school diploma, 50.5 percent has completed high school and 35.9 percent have completed a college degree. (Table 53, Technical Appendix). HEALTH BEHAVIORS The Florida Department of Health conducts the Behavioral Risk Factor Surveillance System (BRFSS) with financial and technical assistance from the Centers for Disease Control and Prevention (CDC). This statebased telephone surveillance system collects data on individual risk behaviors and preventive health practices related to the leading causes of morbidity and mortality in the United States. The most recent data available for Alachua County is for 2013. COMMUNITY HEALTH STATUS ASSESSMENT PAGE 18

ALACHUA COUNTY COMMUNITY HEALTH ASSESSMENT (CHA) Health Behavior information for Alachua County was drawn from the UF Health Shands Hospital Needs Assessment Platform. Target values on the UF Health Shands Hospital Needs Assessment Platform include the nation-wide Healthy People 2020 (HP2020) goals as well as locally set goals. Below are various indicators about Health Behaviors for adults in Alachua County. The percentage for Florida as well as for the United States is included when available. The data for Health behaviors in Alachua County can be referenced in Table 75 in the Technical Appendix. Health behavior percentages by selected indicators, 2013: The percent of Alachua County adults who currently have Asthma is 12.9 percent in 2013. This is higher than both the percent for the state of Florida (8.3 percent) and the percent for the US (9.0 percent). The percent of adults with Diabetes in Alachua is 7.2 in 2013, which is slightly better than the Florida percent at 11.2 and the percent for the US at 9.7. Alachua County adults have less access to exercise opportunities than their Florida counterparts. For Alachua County in 2013, 70.9 percent of adults have access to exercise opportunities compared to 92.8 percent in the state. The percent of adults Who Are Obese in Alachua County in 2013 is similar to the state with 24.4 percent compared to the state at 26.4 percent. Adults who are Overweight or Obese in 2013 for Alachua County is 56.8 percent. In Florida, 62.8 percent of adults are overweight or obese and in the US 64.8 percent of adults are overweight or obese. COMMUNITY HEALTH STATUS ASSESSMENT PAGE 19

ALACHUA COUNTY COMMUNITY HEALTH ASSESSMENT (CHA) FIGURE 6: PERCENT OVERWEIGHT OR OVERWEIGHT & OBESE, ALACHUA COUNTY AND FLORIDA, 2013. 70 60 50 40 30 20 10 0 % Adults Obese % Adults Obese or Overweight Alachua County Florida United States Source: Table 75, Alachua County Technical Appendix 2016, prepared by WellFlorida Council. The percent of adults Who Are Sedentary in Alachua County for 2013 is 19.7. This percent is lower than both Florida at 27.7 percent and the US at 25.3 percent. The percent of adults Who Drink Excessively in Alachua County is higher than Florida. In 2013, 19.1 percent of adults drink excessively compared to 17.6 percent in Florida. 15.9 percent of adults in Alachua County smoke, compared to 16.8 percent in Florida and 19.0 percent in the US for 2013. Alachua County adults generally reported their own personal health as Good or Better more so than the state and the US. In Alachua County for 2013, 88.8 percent of adults reported their own health as Good or Better compared to Florida at 80.5 percent and the US at 83.3 percent. Infectious Disease The Chlamydia Incidence Rate (Cases Per 100,000 Population) for Alachua County in 2014 is 771.9, which is much greater than the Florida rate at 425.3 per 100,000 population (Table 72, Technical Appendix). The Gonorrhea Incidence Rate (Cases Per 100,000 Population) for Alachua County in 2014 is 160.4, compared to the Florida rate at 105.4 per 100,000 population (Table 72, Technical Appendix). COMMUNITY HEALTH STATUS ASSESSMENT PAGE 20

ALACHUA COUNTY COMMUNITY HEALTH ASSESSMENT (CHA) HIV Incidence Rate (Cases Per 100,000 Population) for Alachua County in 2014 is 32.3, which is similar to the Florida rate of 31.4 per 100,000 population (Table 72, Technical Appendix). HEALTHCARE ACCESS Although health insurance and access to healthcare do not necessarily prevent illness, early intervention and long term management of resources can help to maintain a quality of life and minimize premature death. Therefore, it is useful to consider insurance coverage and healthcare access in a community health needs assessment. The Technical Appendix includes data on insurance coverage, ER utilization and access to physicians. Key findings from these data sets are presented below. Uninsured The percent of Alachua County s population that is uninsured for All Ages is lower than the state, with Alachua County at 14.7 percent and Florida at 19.6 percent (Table 48, Technical Appendix). For the years 2009-2013, the percent of Alachua County s uninsured children (under the age of 19) has remained slightly lower than the Florida percent. In 2013, the percentage of uninsured children in Alachua County was 9.7 percent compared to Florida at 11.9 percent (Table 47, Technical Appendix). Figure 7 shows the trends in percent uninsured under age 19 population, Alachua County and Florida from 2009-2013. FIGURE 7: PERCENT UNINSURED UNDER 19 POPULATION, ALACHUA COUNTY AND FLORIDA, 2009-2013. 16 14 12 10 8 2009 2010 2011 2012 2013 Alachua County Florida Source: Table 47, Alachua County Technical Appendix 2016, prepared by WellFlorida Council. COMMUNITY HEALTH STATUS ASSESSMENT PAGE 21

ALACHUA COUNTY COMMUNITY HEALTH ASSESSMENT (CHA) The percentage of uninsured adults 18-64 years in Alachua County has been similar to yet lower than the Florida percent every year from 2009-2013. In 2013, the percentage of uninsured adults in Alachua County was 21.9 percent compared to Florida at 28.8 percent (Table 47, Technical Appendix). The percentage of uninsured adults in the 40-64 age range in Alachua County was 17.3 percent in 2013 compared to Florida adults in the same age range at 24.5 percent. For uninsured adults aged 50-64 in Alachua County, percent uninsured was at 16.1 percent in 2013 compared to Florida at 22.0 percent (Table 47, Technical Appendix). Medicare Population by Selected Diseases The Medicare population percentages by selected diseases for 2012 in Alachua County are seen below. The percentages for Florida as well as for the United States are included when available. Alachua County s percentages for Medicare population are generally similar to Florida s percentages. The data for age- Medicare population percentages by selected diseases for 2012 in Alachua County can be referenced in Table 60 in the Technical Appendix. Medicare population percentages by selected diseases, 2012: Atrial Fibrillation in Alachua County: 7.4 (9.4 FL; 7.8 US) Cancer in Alachua County: 8.2 (9.7 FL; 7.9 US) COPD in Alachua County: 10.5 (13.6 FL; 11.3 US) Diabetes in Alachua County: 25.3 (28.5 FL; 27.0 US) Hyperlipidemia in Alachua County: 43.7 (55.5 FL; 44.8 US) Hypertension in Alachua County: 55.7 (60.8 FL; 55.5 FL) Ischemic Heart Disease in Alachua County: 26.2 (37.1 FL; 28.6 US) Access to Health Providers From 2007-2013, the Dentist rate per 100,000 population in Alachua County has been near 100 per 100,000 population. In 2013, the Dentist rate per 100,000 population in Alachua County was 158 per 100,000 population compared to Florida at 53 per 100,000 population (Table 70, Technical Appendix). The Non-Physician Primary Care Provider Rate (providers per 100,000 population) in 2014 for Alachua County was 211 per 100,000 population, which is much higher when compared to Florida at 67 Non- Physician Primary Care Providers per 100,000 population (Table 70, Technical Appendix). Primary Care Provider Rate (providers per 100,000 population) in 2012 for Alachua County was 134 per 100,000 population, compared to Florida at 70 per 100,000 population (Table 70, Technical Appendix). COMMUNITY HEALTH STATUS ASSESSMENT PAGE 22

ALACHUA COUNTY COMMUNITY HEALTH ASSESSMENT (CHA) Healthcare Utilization ER Visits The age-adjusted Emergency Room rates by cause per 10,000 population in Alachua County from 2012-2014 are below. The Florida age-adjusted ER rates by cause per 10,000 population are also included. This information can be referenced in Table 65 of the Technical Appendix. Age-adjusted ER rates by cause per 10,000 population, 2012-2014: Dental Problems for Alachua County (All Ages): 99.7 (FL 78.4) Asthma for Alachua County (All Ages): 49.4 (FL 60.2) Adolescent Suicide and Intentional Self-inflicted Injury (Ages 12-17) for Alachua County: 15.7 (FL 17.4) Pediatric Asthma for Alachua County (Under 18 Years): 106.8 (FL 119.5) Pediatric Mental Health for Alachua County (Under 18 Years): 17.8 (FL 24.3) Adult Asthma for Alachua County (18+ Years): 29.4 (FL 39.6) Alcohol Abuse for Alachua County (18+ years): 32.2 (FL 27.7) Bacterial Pneumonia for Alachua County (18+ years): 15.3 (FL 15.2) COPD for Alachua County (18+ years): 11.9 (FL 18.5) Dehydration for Alachua County (18+ years): 10.1 (FL 14.1) Diabetes for Alachua County (18+ years): 18.9 (FL 22.5) Mental Health for Alachua County (18+ years): 40.0 (FL 70.4) Substance Abuse for Alachua County (18+ years): 9.3 (FL 15.3) Most notably from the Alachua County data on ER rates, Alachua County is much worse off than the state when it comes to age-adjusted ER rates for Dental Problems and Alcohol Abuse. However, Alachua County is doing better than the state in age-adjusted ER rates from Mental Health and Substance Abuse. The data for age-adjusted ER rates by cause per 10,000 population in Alachua County from 2012-2014 can be referenced in Table 65 in the Technical Appendix. Hospitalizations The age-adjusted hospitalization rates by cause per 10,000 population in Alachua County from 2012-2014 are below. The Florida age-adjusted hospitalization rates by cause per 10,000 population are also included. This information can be referenced in Table 66 of the Technical Appendix. Age-adjusted Hospitalization rates by cause per 10,000 population, 2012-2014: Adolescent Suicide and Intentional Self-Inflicted Injury for Alachua County (12-17 Years of Age): 49.5 (FL 34.5) Adult Asthma for Alachua County (18+ Years): 18.0 (FL 12.9) Alcohol Abuse for Alachua County (18+ Years): 17.7 (FL 10.9) COMMUNITY HEALTH STATUS ASSESSMENT PAGE 23

ALACHUA COUNTY COMMUNITY HEALTH ASSESSMENT (CHA) Heart Failure for Alachua County (18+ years): 18.7 (FL 34.7) Hypertension for Alachua County (18+ years): 13.1 (FL 8.4) Mental Health for Alachua County (18+ years): 44.4 (FL 75.3) Asthma for Alachua County (All Ages): 20.8 (FL 13.8) Pediatric Asthma for Alachua County (Under 18 years): 29.1 (FL 16.3) Alachua County fares worse than the state in age-adjusted hospitalization rates per 100,000 population when it comes to Adolescent Suicide, Asthma (All Ages, Adult and Pediatric), Alcohol Abuse and Hypertension. Alachua County is much better than the state, however, in age-adjusted hospitalization rates for the causes of Heart Failure and Mental Health. The data for age-adjusted hospitalizations by cause per 10,000 population in Alachua County from 2012-2014 can be referenced in Table 66 in the Technical Appendix. Cancer In Alachua County, Cancer Incidences per 100,000 population from 2010-2012 are below. Cancer Incidences per 100,000 population for Florida as well as Cancer Incidence data for the United States is included when available. This information can be referenced in Table 67 of the Technical Appendix. Cancer incident cases by type, per 100,000 population, 2010-2012: Breast Cancer for Alachua County (females only): 114.4 (FL 90.4) Cervical Cancer for Alachua County: 5.8 (FL 6.1; US 7.1) Colorectal Cancer for Alachua County: 40.7 (FL 33.7; US 39.9) Lung and Bronchus Cancer for Alachua County: 70.9 (FL 58.0) Melanoma for Alachua County: 25.6 (FL 17.5) Oral Cavity and Pharynx Cancer for Alachua County: 16.5 (FL 12.4) Prostate Cancer for Alachua County: 129.4 (FL 114.6) The Cancer Incidence data for Alachua County shows that Alachua fares worse than Florida in multiple cancer sites, including incidence of Breast Cancer, Colorectal Cancer, Lung and Bronchus Cancer, Melanoma, Oral Cavity and Pharynx Cancer, and Prostate Cancer. Alachua fares slightly better than the state of Florida as well as better than the United States in terms of Cervical Cancer Incidence. The data for Cancer Incidences per 100,000 population in Alachua County from 2010-2012 can be referenced in Table 67 in the Technical Appendix. Table 4 below displays cancer screening and behavior for Alachua County and Florida, 2002-2013. As seen in the table, Alachua County is doing worse than the state in Pap Test History. COMMUNITY HEALTH STATUS ASSESSMENT PAGE 24

ALACHUA COUNTY COMMUNITY HEALTH ASSESSMENT (CHA) TABLE 4: CANCER SCREENING AND BEHAVIOR, ALACHUA COUNTY, FLORIDA AND HP2020, 2007-2013 Indicator Year Alachua County Florida HP 2020 2002 67.8 --- --- Mammogram History (Percent) 2007 70.8 --- --- 2010 53.9 --- --- Colon Cancer Screening(Percent) 2013 5.3 --- 13.9 Pap Test History (Percent) 2013 36.7 51.4 --- Source: Table 68, Alachua County Technical Appendix 2016, prepared by WellFlorida Council. HEALTH OUTCOMES One of the best strategies for measuring health and well-being is by examining a community s rates of disease and death. In Alachua County as well as in Florida and the rest of the United States premature disease and death are primarily attributable to chronic health issues. Chronic health issues typically develop throughout the course of life and often require careful management for prolonged periods of time. This section focuses on the health outcomes (morbidity and mortality) of Alachua County residents. Alachua County data will be compared to state of Florida data when possible. LIFE EXPECTANCY The University of Washington, Institute for Health Metrics and Evaluation, released a complete time series for life expectancy for all U.S. counties from 1987 to 2010 for each sex, for all races combined, for Whites and for Blacks. Life Expectancy data can be found in Tables 3 and 4 of the Technical Appendix. The life expectancy for Alachua County males is 75.6 years of age, which is 0.9 years lower than the Florida life expectancy of 76.5 (For 2009 - Table 3, Technical Appendix). Life expectancy for Alachua County males is also lower than their Florida counterparts when it comes to race: the life expectancy for Alachua County White males is 0.4 years lower than the Florida life expectancy for White males (76.5 Alachua vs. 76.9 Florida for 2009). This is also true for Alachua County Black males when compared to the state: the life expectancy for Black males in Alachua County is 71.3 years of age compared to Black males in Florida at 72.7 (For 2009 Table 3, Technical Appendix). COMMUNITY HEALTH STATUS ASSESSMENT PAGE 25

Life Expectancy in Years ALACHUA COUNTY COMMUNITY HEALTH ASSESSMENT (CHA) Within the county, there is a disparity between the life expectancy of White and Black males. The life expectancy of White Alachua County males is 76.5 years, 5.2 years longer than the life expectancy of Black Alachua County males which is 71.3 years (For 2009 - Table 4, Technical Appendix). When examined along with the life expectancy for males in the United States, Alachua County trends lower than both the state and the country. Figure 8 shows the life expectancy for males by year, Alachua County, Florida and the United States, 1987-2009. FIGURE 8: LIFE EXPECTANCY FOR MALES BY YEAR, ALACHUA COUNTY AND FLORIDA, 1987-2009. 77.0 76.0 75.0 74.0 73.0 72.0 71.0 Alachua County Florida United States 70.0 69.0 68.0 Source: Table 3, Alachua County Technical Appendix 2016, prepared by WellFlorida Council. The life expectancy for Alachua County females is 1.7 years shorter than Florida females, with 80.4 years in Alachua County compared to 82.1 years in Florida (For 2009 - Table 4, Technical Appendix). Alachua County females also have a slightly lower life expectancy within the county than their Florida counterparts when it comes to race: life expectancy for Alachua County White females is 81.2, which is 1.6 years lower than the Florida life expectancy of 82.6 (For 2009 Table 4, Technical Appendix); and life expectancy for Alachua County Black females is 77.3, which is 1.5 years lower than the Florida life expectancy of 78.8 (For 2009 Table 4, Technical Appendix). Within the county, there is a disparity between the life expectancy of White and Black females. The life expectancy of White Alachua County females is 81.2 years, 3.9 years longer than the life expectancy of Black Alachua County females which is 77.3 years (For 2009 - Table 4, Technical Appendix). COMMUNITY HEALTH STATUS ASSESSMENT PAGE 26

Life Expectancy in Years ALACHUA COUNTY COMMUNITY HEALTH ASSESSMENT (CHA) When examined along with the life expectancy for females in the United States, Alachua County trends lower than both the state and the country. Figure 9 shows the life expectancy for females by year, Alachua County and Florida, 1987-2009. FIGURE 9: LIFE EXPECTANCY FOR FEMALES BY YEAR, ALACHUA COUNTY AND FLORIDA, 1987-2009. 83.0 82.0 81.0 80.0 79.0 78.0 Alachua County Florida United States 77.0 76.0 75.0 Source: Table 4, Alachua County Technical Appendix 2016, prepared by WellFlorida Council. MORTALITY The age-adjusted death rates by cause per 100,000 population in Alachua County from 2012-2014 are below. In addition to the Florida age-adjusted death rates by cause, the Healthy People 2020 benchmarks for the same causes are included. This information can be referenced in Table 61 of the Technical Appendix. Age-adjusted death rates by cause per 100,000 population, 2012-2014: All Cancers for Alachua County: 176.0 (FL 158.1; HP 2020 161.4) Breast Cancer for Alachua County: 23.5 (FL 20.2; HP 2020 20.7) Colorectal Cancer for Alachua County: 16.5 (FL 13.8; HP 2020 14.5) Lung cancer for Alachua County: 44.4 (FL 43.4; HP 2020 45.5) Oral cancer for Alachua County: 3.9 (FL 2.7; HP 2020 2.3) Prostate cancer for Alachua County: 26.5 (FL 17.5; HP 2020 21.8) COMMUNITY HEALTH STATUS ASSESSMENT PAGE 27

ALACHUA COUNTY COMMUNITY HEALTH ASSESSMENT (CHA) Stroke for Alachua County: 43.3 (FL 33.8; HP 2020 34.8) Coronary Heart Disease for Alachua County: 87.9 (FL 99.3; HP 2020 103.4) Diabetes for Alachua County: 32.7 (FL 19.8) Pneumonia for Alachua County: 9.7 (FL 9.7) Motor Vehicle Collisions for Alachua County: 8.1 (FL 12.3) Suicide for Alachua County: 13.5 (FL 13.9; HP 2020 10.2) Unintentional Injuries for Alachua County: 38.4 (FL 41.1; HP 2020 36.4) As seen in the data above, Alachua County is worse off than the state when it comes to age-adjusted death rates for All Cancers, Breast Cancer, Colorectal Cancer, Oral Cancer and Prostate Cancer. Alachua County also fares worse than the state for age-adjusted death rates from Diabetes and Stroke. Alachua County is similar to the state when it comes to age-adjusted deaths from Lung cancer, Pneumonia, and Suicide. Alachua County is slightly better than the state in age-adjusted death rates from Coronary Heart Disease, Motor Vehicle Collisions, and Unintentional Injuries. The data for age-adjusted death rates by cause per 100,000 population in Alachua County from 2012-2014 can be referenced in Table 61 in the Technical Appendix. MATERNAL AND INFANT HEALTH Indicators for Maternal and Infant Health in 2014 for Alachua County are below. In addition to the Maternal and Infant Health indicators for the state of Florida, the Healthy People 2020 benchmarks for the same health outcomes are included. The percent of babies who were born low birth weight in 2014 for Alachua County is 9.8, which is higher than the state percent of 8.7 percent. The Healthy People 2020 benchmark for low birthweight is 7.8 percent (Table 64, Technical Appendix). 78.8 percent of mothers received early prenatal care in 2014 for Alachua County, which is similar to Florida at 79.4 percent (HP 2020: 77.9) (Table 64, Technical Appendix). The percent of preterm births for Alachua County in 2014 is 12.1, similar to the Florida percent of 13.4 (HP 2020: 11.4) (Table 64, Technical Appendix). The percent of teen births for Alachua County in 2014 is much lower than the state, with Alachua County at 11.7 percent and Florida at 21.9 percent (Table 64, Technical Appendix). The percent of repeat teen births in 2014 for Alachua County is 10.2, which is lower than state s percent at 16.5 (Table 64, Technical Appendix). Infant mortality rates per 1,000 live births in 2014 for Alachua County is 9.6. This is higher than the infant mortality rate for the state of Florida at 6.0 per 1,000 live births. The Healthy People 2020 benchmark for infant mortality is 6.0 per 1,000 (Table 64, Technical Appendix). COMMUNITY HEALTH STATUS ASSESSMENT PAGE 28